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Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions

BMC Musculoskeletal Disorders volume 23, Article number: 324 (2022) Cite this article

Abstract

Background

Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted.

Methods

The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014–2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used.

Results

PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43–68) and 47 (31–61); other symptoms, 50 (40–65) and 36 (19–50); function in daily living, 54 (41–65) and 44 (31–55); function in sports and recreation, 56 (38–75) and 40 (15–64); joint-related quality of life, 69 (50–81) and 56 (38–75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients.

Conclusions

We found excellent PROM results after fast-track HA and KA with no postoperative restrictions. We believe that a fast-track program focusing on mobilization without any postoperative restrictions is superior for most patients, but further comparative studies are warranted.

Peer Review reports

Background

Fast-track

Fast-track surgery, also called the enhanced recovery surgical program, implies a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery [1]. The introduction of fast-track total knee arthroplasty (KA) and total hip arthroplasty (HA) has been a tremendous success [2, 3], and the concepts are well established, including optimized logistics and evidence-based treatment [4, 5], leading to a reduced postoperative length of stay (LOS) [6], lower mortality and morbidity rates [3, 7, 8], and greater patient satisfaction [8]. Fast-track concepts can only be successfully implemented through close interdisciplinary teamwork. Preoperatively, a patient seminar can help to better prepare patients for surgery; while postoperatively, early mobilization and pain treatment play central roles [9]. An effective follow-up regimen with a focus on early mobilization can reduce postoperative pain and can also result in a shorter LOS [10]. Some claim all patients are eligible for fast-track surgery, and the fast-track concept should be standard at all joint replacement facilities [1, 11].

Postoperative restrictions

Activity restrictions after HA and KA have been common [12], and restrictions following HA for at least 3 months have been widely practiced [13]. There are reports showing that departments with recommendations for activity restrictions have fewer dislocations than departments without restrictions [14], but other studies find that fewer lifestyle restrictions and precautions following HA seem to lead not to worse dislocation rates but to earlier and better resumption of activities and greater patient satisfaction, and these results appear to hold up for various surgical approaches [15,16,17]. Hip precautions may unnecessarily exacerbate patient anxiety and fear of dislocation following HA [18]. Emerging evidence suggests that these postoperative restrictions are not necessary [15, 19,20,21].

Patient-reported outcome measures (PROMs)

Although joint arthroplasty is a successful intervention in terms of prosthesis survival [22], 7–34% of patients have persistent pain or otherwise do not benefit from the operation [23]. Patient-reported outcome measures (PROMs) allow us to examine the patient perspective on joint arthroplasty, have been used increasingly in both orthopedic surgery and health services in general over the last decade [24, 25] and are increasingly used in national arthroplasty registries [26]. PROMs are therefore highly relevant outcome measures after arthroplasty [27].

Aim

Fast-track joint arthroplasty and minimal postoperative activity restrictions are both increasingly common, but few reports on combining these programs have been published. We aimed to assess the combined programs’ postoperative results from a patient perspective by using PROMs.

Methods

Patients

All patients over 18 years of age admitted for elective hip or knee arthroplasty (HA or KA) at the Department of Orthopaedic Surgery at Stavanger University Hospital (SUH) during 2014–2018 who underwent regular pre- and postoperative assessments were included in the fast-track regimen. All patients meeting these inclusion criteria were encouraged to participate in PROM data collection. Patients with cognitive, language, or other impairments preventing PROM completion were excluded from the present study.

Fast-track regimen

In 2014, we gradually introduced a fast-track regimen consisting of standardized pain medication and standardized information with a focus on mobilization with no postoperative restrictions, postoperative early control at outpatient clinics and PROMs for all scheduled HA and KA patients. Both HA and KA patients were allowed full weight bearing immediately after the operation and had no activity restrictions of any kind. A preoperative PROM program and preoperative assessment at the outpatient clinic were introduced later the same year, and in 2017, we introduced a one-year postoperative PROM program and one-year postoperative control visit at the outpatient clinic for all HA and KA patients. In our fast-track system, the patient was admitted on the day of surgery, and an admission note was made at the outpatient clinic prior to admission. Two weeks before surgery, a full journal recording was made, including blood samples, ECG, X-rays of the joint and information from the operating surgeon. Preoperatively, the patients were assessed, received information and provided PROMs. The standardized premedication consisted of paracetamol 2 g, celecoxib 400 mg and fortecortin 12 mg. If celecoxib or fortecortin was contraindicated, it was replaced by oxycodone 10 to 20 mg. Postoperative mobilization starts as soon as possible, depending on the anesthesia (within 3–6 h). Spinal anesthesia was primarily performed, exceptionally general anesthesia, based on the anesthetists decision. On the first postoperative day, all patients were mobilized guided by a physiotherapist. Our discharge criteria were as follows: ability to get in and out of bed independently, get dressed, go to the toilet, walk with crutches in stairs independently, and no wound leakage. The standardized postoperative pain treatment consisted of paracetamol 1 g × 4, celecoxib 200 mg × 2 and tramadol 50 mg × 3. Six to eight weeks postoperatively, the patients underwent the same assessment as preoperatively, in addition to an X-ray examination. One year postoperatively, the assessment was repeated with the same PROM questionnaires and clinical examination. Only patients requiring additional follow-up at one year (patients with pain from the operated area or subjective instability) were scheduled for a one-year postoperative X-ray examination.

Follow-up within the fast-track regimen consists of the following:

  1. 1)

    Standardized written and oral information with a focus on mobilization and no postoperative restrictions at the early postoperative follow-up visit.

  2. 2)

    Standardized pain medication regimens to minimize opioid use at the early postoperative follow-up visit.

  3. 3)

    Registration of the postoperative course (discharge to their own home, admission to rehabilitation institution, physical therapy, sick leave) at the early postoperative and one-year follow-up visits.

  4. 4)

    An examination of the postoperative status (hip/knee pain, squeaking, leg length discrepancy, knee extension/flexion, knee stability, timed up & go (TUG) test, Trendelenburg sign test, hip abduction test) was performed at the early postoperative and one-year follow-up visits.

  5. 5)

    Registration of postoperative complications (hip dislocation, deep venous thrombosis, nerve damage, superficial infection, deep infection, cerebral insult, pneumonia, urinary tract infection, allergic reaction, other postoperative complications, readmission, death) at the early postoperative and one-year follow-up visits.

  6. 6)

    PROMs: The EQ-5D and Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) at the early postoperative and one-year follow-up visits. The preoperative EQ-5D was included late in the introduction of the fast-track regimen.

  7. 7)

    Patient satisfaction (postoperative general health, operative result, change in general health, change in joint symptoms) at the early postoperative and one-year follow-up visits.

PROMs

All patients provided two different PROMs: one generic, i.e., the EQ-5D, and one condition-targeted, i.e., the HOOS or KOOS.

The EQ-5D is a generic health-related quality of life (QoL) outcome measure that covers five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression [28]. One of five levels of severity is chosen for each dimension, as this 5L-version is more responsive in our patient group [29]. Patients also rated their current state of health from 0 (‘worst imaginable’) to 100 (‘best imaginable’) on a visual analogue scale (VAS). The EQ-5D generates two values for QoL, one from the patient’s perspective (the EQ-VAS; ‘current state of health’) and the other from a societal perspective, the EQ-5D Index (a health profile that can be made into a global health index with a weighted total value for health-related (QoL)), which represents the patients’ description of their own health and how this health state is perceived by the general population. License was obtained from the EuroQol Group (http://www.euroqol.org/), license agreement number: 152277.

The HOOS is hip-specific and includes 40 items [30]. The KOOS is knee-specific and includes 42 items [31]. Both have five subscales: pain, other symptoms (symptoms), activity/function in daily living (ADL), function in sports and recreation (sports) and joint-related QoL. The sum scores of the subscales range between 0 and 100, with higher scores being better. The HOOS and KOOS do not require any license and can be used free of charge. User guides and scoring manuals are available at http://www.koos.nu/index.html. The HOOS and EQ-5D have been shown to be feasible for use in large-scale studies of HA [32].

Definition of success –MCII

A statistically significant change in the PROM score does not necessarily represent a clinically important improvement. Since it can be problematic to interpret changes in scores in a clinically meaningful way [33], different cutoff points can be determined based on anchor questions, i.e., items that establish an external patient-reported reference between the PROM change scores and the patients’ health situation. The minimal clinically important improvement (MCII) is a PROM change score value defined as the minimal change representing a clinically important improvement from the patient’s perspective [34]. We compared each patient’s score to published MCII cutoffs [27, 35, 36]. When more than 75% of the patients achieved joint-specific PROM change scores in all of the most relevant domains (pain, symptoms, ADL and QoL) at or above the MCII cutoff, we defined the result as excellent.

LOS

We examined LOS in the study period and at the start of the organized efforts to reduce LOS at SUH, as this has been a long-term goal since 2007. Fifty randomly selected patients were included in the retrospective assessment to illustrate the change in LOS from 2007 to 2018.

Statistics

All data analyses were performed using SPSS (SPSS, Inc., Chicago, IL, USA). Descriptive statistics of categorical variables are presented as counts and percentages. Due to skewed distributions, continuous variables are presented as medians and interquartile ranges (IQRs). Parametric statistics, i.e. means, standard deviations (SD), were performed as supplementary analyses to facilitate comparison to previous published arthroplasty registry data.

Ethics

The study was submitted for registration to the Regional Committee for Ethics in Medical Research (2018/268) and considered a follow-up quality-control study under the jurisdiction of the local data protection officer. Due to the use of only anonymous data from patient journals, there was no need for informed written consent from patients, and the study was approved by the local data protection officer (journal number 6/2018). The patients will not receive any treatment in addition to our routine medical treatment.

Results

Description of the study population

In total, we have PROM data for 1508 surgical procedures in 1393 unique patients; 1284 patients contributed data for one surgical procedure; 103 patients contributed data for two surgical procedures; and six patients contributed data for three surgical procedures. When looking at hips and knees separately, we have data for 917 hip replacements in 876 unique (though they may have also undergone knee replacement) patients and 591 knee replacements in 517 unique patients. Patient characteristics are listed in Table 1.

Table 1 Patient characteristics
Full size table

PROM results

The response rate for the different PROMs varied from 80 to 99%. The preoperative, postoperative and one-year follow-up scores, as well as changes in scores between the different assessment times, are presented for the HA and KA patients in Tables 2 and 3, respectively. The median (IQR) preoperative HOOS symptom score was 35 (25–45) and improved to 90 (80–100) at the one-year follow-up and was the HOOS score with the least improvement; i.e., all other PROMs showed greater absolute improvement for these HA patients. The median (IQR) preoperative HOOS QoL score was 19 (6–31) and improved to 94 (75–100) at the one-year follow-up and was the HOOS score with the highest improvement. Similarly, the KOOS score with the least absolute improvement (KOOS symptoms) improved from 50 (36–61) to 89 (79–96) at the one-year follow-up. The KOOS QoL improved the most, from 19 (11–25) to 75 (56–94) at the one-year follow-up.

Table 2 Pre- and postoperative PROM scores and change scores for hip arthroplasty patients
Full size table
Table 3 Pre- and postoperative PROM scores and change scores for knee arthroplasty patients
Full size table

The corresponding results of parametric statistical analysis are given in Supplementary Tables S1 and S2. The percentage of patients achieving the MCII cutoff for the different subscales is given in Table 4. Eighty-seven percent of HA patients and 79% of KA patients achieved joint-specific PROM change scores for all of pain, symptoms, ADLs and QoL at or above the MCII cutoff.

Table 4 MCII cutoff and percent of patients achieving cutoff
Full size table

LOS

Data on LOS are available as metadata from our hospital’s journal systems since 2012. Data prior to this are available through manual searching of the journal systems. A retrospective assessment of LOS in 30 consecutive THAs and 20 TKAs from June 2007 and 30 consecutive THAs and 19 TKAs from November 2007 showed that LOS for HA patients was reduced from 17 days (mean)/15 days (median) to 11 days (mean)/10 days (median). The LOS for KA patients in the same period was reduced from 13 days (mean)/13 days (median) to 11 days (mean)/9 days (median). The LOS changed from 4.8 days (mean) for HA patients and 5.1 days (mean) for KA patients in 2013 to 2.9 (mean) for HA patients and 3.2 days (mean) for KA patients in 2018, representing LOS before and after introduction of the fast-track regimen.

Discussion

We found excellent PROM results after HA and KA in our fast-track program with no postoperative restrictions.

Berg et al. examined 1-year PROM results in HA and KA fast-track programs in a large Swedish observational study and found that fast-track programs seem to be at least as good as conventional care [37]. In their article, there was no information on the use of postoperative restrictions, but based on another study, > 60% of operating centers seemed to have restrictions following hip arthroplasty [38]—the use of postoperative restrictions following knee arthroplasty is uncertain. In our fast-track program without any postoperative restrictions, the KA patients achieved better 1-year results for all KOOS subscores compared to the Swedish cohort. Too few of our patients answered the EQ-5D at 1 year postoperatively to enable a meaningful comparison.

Anchor-based MCII estimates for the patient group at one year were used when available [35]. For HOOS QoL, the 75th percentile approach cutoff (25) was used instead of the mean score approach (17) [35] due to a lower minimal detectable change (21) [27]. When no anchor-based MCII estimation for the PROMs and patient group at one year was found, two-year cutoff estimations were used [36] to ensure no overestimation of patient-reported results.

Dislocations and reoperations

In 2009, 87% and 95% of American hip and knee surgeons recommended postoperative activity restrictions (avoiding high-impact activities such as running and jogging) [39]. Unrestricted mobilization following KA might be viewed as less controversial than following HA, but in 2018, 44% of members of the American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society universally prescribed precautions [40]. In the UK, hip precautions are routinely provided by the majority of hospitals [41, 42]. The use of postoperative restrictions following primary HA differs between Nordic countries, with between 19% (in Norway) and 50% (in Denmark) of hospitals performing primary HA allowing mobilization without any restrictions [38]. Over the last five years, there has been a strong tendency toward less restrictive mobilization, but still and especially in Norway, few hospitals allow mobilization without restrictions [38]. It has been a fear that fast-track HA and KA with no postoperative restrictions will lead to more hip dislocations and more reoperations. An increase in the rates of readmission and revision after fast-track implementation has been reported [6]. The revision rate after fast-track HA has been reported to be from 1.4 to 2.9% within 90 days and 2.9–5.5% within 1 year [6]. The removal of mobilization restrictions following primary HA performed with a posterolateral approach did not lead to an increased risk of dislocation within 90 days [43]. Van der Weegen et al. [44] also found that patients may be managed safely with minimal restrictions following posterior-approach HA if combined with the frequent use of larger femoral heads. Crompton et al. found no impact on the dislocation rate or PROM scores following HA performed through a posterior approach, regardless of the use of hip precautions [45]. We also did not find indications of an increased revision rate due to the HA/KA management at SUH: the relative risk for revision after HA at SUH from 2007–2018 compared to all other Norwegian hospitals was 0.77 (95% CI: 0.64–0.93), and SUH had a lower percentage of revisions due to hip dislocation than the national mean [46]. The relative risk for revision after KA at SUH from 2008–2018 compared to all other Norwegian hospitals was 0.82 (95% CI: 0.64–1.05) [46]. There is no evident change in revision of hip or knee arthroplasties due to the combined enhanced recovery program (supplementary Table S1, S2). A possible change in HA patients could be attributed to change in surgical approach (in 2013 almost exclusively direct lateral, changed to 20% anterolateral, 25% posterior and 55% direct lateral in 2016, to almost exclusively posterior approach in 2020), change in fixation (in 2013 almost exclusively reverse hybrid, in 2020 20% hybrid, 10% reverse hybrid, < 10% cemented and > 50% uncemented), different components, different head size (in 2013 100% 28 mm, in 2020 > 30% 36 mm and > 60% 32 mm) or different comorbidity level of patients (in 2013 > 10% the American Society of Anesthesiologists physical status classification (ASA) 1, < 70% ASA 2, > 20% ASA3, in 2020 < 5% ASA1, > 50% ASA2, < 40% ASA3, < 5% ASA 4) [47].

Local data compared to arthroplasty registries

Our HA results are comparable to the results from The Norwegian National Advisory Unit on Arthroplasty and Hip Fractures, the Swedish Hip Arthroplasty Registry and the Danish Hip Arthroplasty Register (Supplementary Table S3). The Norwegian national registry contain only 1 year PROM data from 1001 hip arthroplasty patients (37% response rate), SUH did not contribute to these national data due to technical issues. The Swedish Hip Arthroplasty Registry has a good response rate of 81% preoperatively and 82% postoperatively (supplementary Table S3).

Our KA results are comparable to the Swedish published results. 37% of the Swedish patients undergoing a primary operation contributed PROM data [48], and the response rate has increased to 78% in 2019 (supplementary Table S4).

Limitations and strengths

Several methodological limitations should be taken into consideration when interpreting the results of the present study. When combining different protocol changes (i.e., fast-track surgery and no postoperative restrictions), the effect of each individual change is difficult to examine. On the other hand, when examining a regimen including different concepts, the data represent the combination of concepts, which is most important in clinical practice. Few patients (< 100 in each group) answered the preoperative EQ-5D questionnaire. The response rate for all PROMs was high (≥ 80%) and much higher than the minimal response rate of PROMs published for HA patients [49]. High response rates ensure generalizability and minimize selection bias. A response rate ≥ 80% is usually considered to be adequate and sufficiently representative of the sample studied [50]. We used well-validated PROMs for the patient group, with validated setting feasibility [32]. Standardized format paper PROMs were used. All returned questionnaire forms were scanned electronically using a validated automated form-processing technique [51]. Multiple factors (surgical approach, change in fixation, different components, different head size and different comorbidity level of patients) changed during the introduction of our fast-track pathway, and our study is not aimed at establishing an etiology between fast-track, postoperative restrictions and outcome, but we have shown that it is possible to achieve excellent PROM results in a real-world combined enhanced recovery surgical program without postoperative restrictions.

Importance

This study shows that patients can have excellent outcomes after HA and KA with no postoperative restrictions in a fast-track setting. Allowing mobilization without restrictions may further improve fast-track programs by speeding up recovery and shifting focus from movement restriction to optimized mobilization. An effective analgesic regimen pre- and postoperatively is important to achieve the best possible early mobilization. By using PROMs in the fast-track setting, it could be possible to reduce the follow-up of patients treated successfully with joint arthroplasty and target patients at risk.

Conclusion

We found excellent PROM results after HA and KA without any postoperative restrictions in our fast-track program. We believe that a fast-track program with a focus on mobilization and without postoperative restrictions is superior for most patients. Further comparative studies including PROM endpoints and subgroups from the whole range of arthroplasty patients are warranted to examine the influence of postoperative restrictions on outcome.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

HA:

Hip Arthroplasty

KA:

Knee Arthroplasty

PROM:

Patient-Reported Outcome Measures

EQ-5D:

EuroQol questionnaire

HOOS:

Hip disability and Osteoarthritis Outcome Score

KOOS:

Knee injury and Osteoarthritis Outcome Score

LOS:

Length of stay

SUH:

Stavanger University Hospital

TUG test:

Timed Up & Go test

QoL:

Quality of Life

VAS:

Visual Analogue Scale

ADL:

Activity in Daily Living

MCII:

Minimal Clinically Important Improvement

IQR:

InterQuartile Ranges

SD:

Standard Deviations

CI:

Confidence Intervals

References

  1. Hansen TB, et al. [Fast-track hip arthroplasty]. Ugeskr Laeger. 2017;179(51):V03170252.

    PubMed  Google Scholar 

  2. Kehlet HJDO. History and future challenges in fast-track hip and knee arthroplasty. Orthopade. 2020;49(4):290–2.

    Article  CAS  PubMed  Google Scholar 

  3. Fransen BL, et al. Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up. Arch Orthop Trauma Surg. 2018;138(9):1305–16.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Tan NLT, Hunt JL, Gwini SM. Does implementation of an enhanced recovery after surgery program for hip replacement improve quality of recovery in an Australian private hospital: a quality improvement study. BMC Anesthesiol. 2018;18:64.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Vehmeijer SBW, Husted H, Kehlet H. Outpatient total hip and knee arthroplasty: Facts and challenges. Acta Orthop. 2018;89(2):141–4.

    Article  PubMed  Google Scholar 

  6. Pamilo KJ, et al. Reduced length of uninterrupted institutional stay after implementing a fast-track protocol for primary total hip replacement: Register-based analysis of 4 hospitals and 3,193 replacements. Acta Orthop. 2018;89(1):10–6.

    Article  PubMed  Google Scholar 

  7. Castorina S, et al. Clinical evidence of traditional vs fast track recovery methodologies after total arthroplasty for osteoarthritic knee treatment. A retrospective observational study. Muscles Ligaments Tendons J. 2017;7(3):504–13.

    Article  PubMed  Google Scholar 

  8. Klapwijk LCM, et al. The first 6 weeks of recovery after primary total hip arthroplasty with fast track: A diary study of 94 patients. Acta Orthop. 2017;88(2):140–4.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Nöth U, et al. Fast-Track-Strategien in der Hüftendoprothetik. Der Orthopäde. 2019;48(4):330–6.

    Article  PubMed  Google Scholar 

  10. Smith TO, et al. Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty. Orthop Traumatol Surg Res. 2012;98(5):499–505.

    Article  CAS  PubMed  Google Scholar 

  11. Gromov K, et al. Fast-track total knee arthroplasty. Ugeskr Laeger. 2017;179(38):V04170300.

    PubMed  Google Scholar 

  12. Vogel LA, et al. Physical activity after total joint arthroplasty. Sports Health. 2011;3(5):441–50.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Husted H, et al. Traditions and myths in hip and knee arthroplasty. Acta Orthop. 2014;85(6):548–55.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jorgensen CC, et al. Hip dislocations after 2,734 elective unilateral fast-track total hip arthroplasties: incidence, circumstances and predisposing factors. Arch Orthop Trauma Surg. 2014;134(11):1615–22.

    Article  PubMed  Google Scholar 

  15. van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil. 2016;30(4):329–39.

    Article  PubMed  Google Scholar 

  16. Peters A, et al. Less Postoperative Restrictions Following Total Hip Arthroplasty With Use of a Posterolateral Approach: A Prospective, Randomized. Noninferiority Trial The Journal of Arthroplasty. 2019;34(10):2415–9.

    Article  PubMed  Google Scholar 

  17. Tetreault MW, et al. Are Postoperative Hip Precautions Necessary After Primary Total Hip Arthroplasty Using a Posterior Approach? Preliminary Results of a Prospective Randomized Trial. J Arthroplasty. 2020;35(6S):S246–51.

    Article  PubMed  Google Scholar 

  18. Lightfoot CJ, et al. Hip precautions after total hip replacement and their discontinuation from practice: patient perceptions and experiences. Disabil Rehabil. 2021;43(20):2890–6. https://doi.org/10.1080/09638288.2020.1722262.

  19. Smith TO, et al. Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty. Cochrane Database Syst Rev. 2016;7(7):Cd010815.

    PubMed  Google Scholar 

  20. Barnsley L, Barnsley L, Page R. Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review. Geriatr Orthop Surg Rehabil. 2015;6(3):230–5.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lightfoot CJ, et al. Evaluation of hip precautions following total hip replacement: a before and after study. Disabil Rehabil. 2021;43(20):2882–9. https://doi.org/10.1080/09638288.2020.1721575.

  22. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. The Lancet. 2007;370(9597):1508–19.

    Article  Google Scholar 

  23. Beswick AD, et al. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Gagnier JJ. Patient reported outcomes in orthopaedics. J Orthop Res. 2017;35(10):2098–108.

    Article  PubMed  Google Scholar 

  25. Calvert M, et al. Maximising the impact of patient reported outcome assessment for patients and society. BMJ. 2019;364:k5267.

    Article  PubMed  Google Scholar 

  26. Wilson I, et al. Orthopaedic registries with patient-reported outcome measures. EFORT open reviews. 2019;4(6):357–67.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Paulsen A. Patient reported outcomes in hip arthroplasty registries. Dan Med J. 2014;61(5):B4845.

    PubMed  Google Scholar 

  28. Herdman M, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 2011;20(10):1727–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Jin X, et al. Responsiveness of the EQ-5D-3L and EQ-5D-5L in patients following total hip or knee replacement. Qual Life Res. 2019;28(9):2409–17.

    Article  PubMed  Google Scholar 

  30. Nilsdotter AK, et al. Hip disability and osteoarthritis outcome score (HOOS)–validity and responsiveness in total hip replacement. BMC Musculoskelet Disord. 2003;4:10.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Roos E, et al. Knee Injury and Osteoarthritis Outcome Score (KOOS)—Development of a Self-Administered Outcome Measure. J Orthop Sports Phys Ther. 1998;28(2):88–96.

    Article  CAS  PubMed  Google Scholar 

  32. Paulsen A, et al. Feasibility of 4 patient-reported outcome measures in a registry setting. Acta Orthop. 2012;83(4):321–7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Quintana JM, et al. Outcomes after total hip replacement based on patients’ baseline status: What results can be expected? Arthritis Care Res. 2012;64(4):563–72.

    Article  Google Scholar 

  34. Tubach F, Giraudeau B, Ravaud P. The variability in minimal clinically important difference and patient acceptable symptomatic state values did not have an impact on treatment effect estimates. J Clin Epidemiol. 2009;62(7):725–8.

    Article  PubMed  Google Scholar 

  35. Paulsen A, et al. Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively. Acta Orthop. 2014;85(1):39–48.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Lyman S, et al. What Are the Minimal and Substantial Improvements in the HOOS and KOOS and JR Versions After Total Joint Replacement? Clin Orthop Relat Res. 2018;476(12):2432–41.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Berg U, et al. Influence of fast-track programs on patient-reported outcomes in total hip and knee replacement (THR/TKR) at Swedish hospitals 2011–2015: an observational study including 51,169 THR and 8,393 TKR operations. Acta Orthop. 2020;91(3):306–12.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Gromov K, et al. Varying but reduced use of postoperative mobilization restrictions after primary total hip arthroplasty in Nordic countries: a questionnaire-based study. Acta Orthop. 2019;90(2):143–7.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2010;25(6 Suppl):2–4.

    Article  PubMed  Google Scholar 

  40. Carli AV, et al. Variation in Use of Postoperative Precautions and Equipment Following Total Hip Arthroplasty: A Survey of the AAHKS and CAS Membership. J Arthroplasty. 2018;33(10):3201–5.

    Article  PubMed  Google Scholar 

  41. Drummond A, et al. Hip Precautions following Primary Total Hip Replacement: A National Survey of Current Occupational Therapy Practice. Br J Occup Ther. 2012;75(4):164–70.

    Article  Google Scholar 

  42. Smith TO, Sackley CM. UK survey of occupational therapist’s and physiotherapist’s experiences and attitudes towards hip replacement precautions and equipment. BMC Musculoskelet Disord. 2016;17:228.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Gromov K, et al. Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation–reply. Acta Orthop. 2015;86(4):518–9.

    Article  PubMed  Google Scholar 

  44. van der Weegen W, et al. It is safe to use minimal restrictions following posterior approach total hip arthroplasty: results from a large cohort study. Hip Int. 2019;29(6):572–7.

    Article  PubMed  Google Scholar 

  45. Crompton, J., L. Osagie-Clouard, and A. Patel, Do hip precautions after posterior-approach total hip arthroplasty affect dislocation rates? A systematic review of 7 studies with 6,900 patients. Acta Orthop. 2020;91(6):687–92. https://doi.org/10.1080/17453674.2020.1795598.

  46. The Norwegian National Advisory Unit on Arthroplasty and Hip Fractures publishes national annual reports. 2019. https://helse-bergen.no/nasjonal-kompetansetjeneste-for-leddproteser-og-hoftebrudd/norwegian-national-advisory-unit-on-arthroplasty-and-hip-fractures#:~:text=%E2%80%8BThe%20Norwegian%20Hip%20Fracture,treatment%20methods%20and%20patient%20care.

  47. The Norwegian National Advisory Unit on Arthroplasty and Hip Fractures publishes national annual reports. 2021. https://helse-bergen.no/nasjonal-kompetansetjeneste-for-leddproteser-og-hoftebrudd/norwegian-national-advisory-unit-on-arthroplasty-and-hip-fractures#:~:text=%E2%80%8BThe%20Norwegian%20Hip%20Fracture,treatment%20methods%20and%20patient%20care.

  48. The Swedish Knee Arthroplasty Register, Annual Report 2018. Malmö: Holmgrens; 2018. https://www.myknee.se/pdf/SVK_2018_Eng_1.0.pdf.

  49. Pronk Y, et al. What is the minimum response rate on patient-reported outcome measures needed to adequately evaluate total hip arthroplasties? Health Qual Life Outcomes. 2020;18(1):379.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Streiner DL, Norman GR. Norman, Health Measurement Scales. 3rd ed. New York: Oxford University Press; 2003.

    Google Scholar 

  51. Paulsen A, Harboe K, Dalen I. Data entry quality of double data entry vs automated form processing technologies: A cohort study validation of optical mark recognition and intelligent character recognition in a clinical setting. Health Sci Rep. 2020;3(4):e210.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We wish to thank Olav Asserson, Senior Consultant Orthopedic Surgeon, former head of joint arthroplasty at the Department of Orthopedic Surgery, Stavanger University Hospital. Dr. Asserson has led the work in developing and implementing our local fast-track regimen.

Funding

This study was supported by Stavanger University Hospital. The funders played no role in the study design, data collection or analysis, interpretation, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger, Norway

    Aksel Paulsen, Ane Djuv & Jarle Ludvigsen

  2. Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway

    Aksel Paulsen

  3. Department of Research, Stavanger University Hospital, Stavanger, Norway

    Ane Djuv & Ingvild Dalen

Authors
  1. Aksel Paulsen
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  2. Ane Djuv
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  4. Ingvild Dalen
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Contributions

Conceived and designed the experiments: AP. Performed the experiments: AP and ID. Analyzed the data: AP and ID. Wrote the paper: AP, ID, AD, and JL. All authors reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Aksel Paulsen.

Ethics declarations

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations.

The study has been performed in accordance with the Declaration of Helsinki and was submitted for registration to the Regional Committees for Medical and Health Research Ethics (REC), considered a follow-up quality-control study under the jurisdiction of the local data protection officer, and has been granted an exemption from requiring ethics approval (REC West 2018/268). Due to the use of no personally identifiable data, only anonymous data from patient journals, the study was exempted informed written consent from patients, and was approved by the local data protection officer (journal number 6/2018).

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Supplementary Information

Additional file 1.

Additional file 2.

Additional file 3:

 Table S1. Number of hip arthroplasties and revision causes, StavangerUniversity Hospital 2013-2020. TableS2. Number of knee arthroplasties and revision causes, Stavanger UniversityHospital 2013-2020. TableS3. Comparison Registry data – SUH data: Mean (SD) pre- and postoperative PROM scoresfor hip arthroplasty patients. TableS4. Comparison Registry data – SUH data: Mean (SD) pre- and postoperative PROMscores for knee arthroplasty patients Comparison Registry data – SUH data: Mean (SD) pre- and postoperative PROMscores for knee arthroplasty patients. 

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Paulsen, A., Djuv, A., Ludvigsen, J. et al. Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions. BMC Musculoskelet Disord 23, 324 (2022). https://doi.org/10.1186/s12891-022-05276-y

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Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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